Our plan to improve the health and wellbeing of older people

A plan for the sector, by the sector

Safer, person-centred healthcare for older people is the main goal of an ambitious five-year plan to integrate and coordinate the health services system in the region.

The PHN and Metro North Health are working to implement directions from the Five Year Health Care Plan for Older People who live in Brisbane North 2017-22.

The PHN and Metro North Health are working to implement directions from the Five Year Health Care Plan for Older People who live in Brisbane North 2017-22.

Consortia model delivers better outcomes in aged care

Giving more choice to people who wish to stay in their own home longer

The PHN leads the healthy@home consortium, an aged care consortium of 18 leading organisations committed to providing high quality Commonwealth Home Support Program (CHSP) services across the region to help older people maximise their health and wellbeing and remain living at home.

The healthy@home consortium strives to affect a broader impact that exceeds the capacity of any one organisation, to support and improve the aged care sector and systems.

The healthy@home model emphasises the importance of building and maintaining strong relationships, developing shared goals and common progress measures, a culture of collaboration and a goal of having a broader impact to support the sector and all older people across our region.

191,000 sessions of care were delivered under the CHSP program to 7,713 clients, including 927 Aboriginal and Torres Strait Islander people.

Healthy@home consortium

Measuring quality of life

In 2020 the healthy@home consortium implemented a shared outcome measure using the Adult Social Care Outcomes Toolkit – Self Complete Tool V4 (ASCOT). The purpose is to measure the quality of life of people receiving in-home aged care support services using an evidence-based tool and identify areas of need to improve service delivery and quality of life outcomes for consumers.

Resource for health professionals

To support the interfaces between aged care and health care systems, the healthy@home consortium developed – in collaboration with Brisbane South PHN – a national resource for GPs, specialists and other health professionals to increase knowledge of services available in the aged care system and improve capacity to refer patients.

The healthy@home consortium recognises social isolation and loneliness as key health issues impacting older Australians and identified existing centre-based respite programs as a unique community aged care service, with significant potential to increase social connectedness.

To enhance the impact of centre-based respite programs in combatting social isolation and loneliness, the consortium conducted a situational analysis of services in the Brisbane North PHN region. They then engaged with consumers, community members and services providers to explore a vision for centre-based respite programs to meet the future needs of older Australians.

Visit the healthy@home website

Assessing eligibility for aged care services

The Regional Assessment Service (RAS), led by the PHN completed 4,637 assessments for aged care services via our Regional Assessment Service consortium.

During the 2020/21 period, RAS assessors adapted to local COVID-19 circumstances by incorporating COVID-safe practices and undertaking telephone assessments when needed to ensure older Australians continued to receive access to aged care services.

The PHN organises regular RAS information sessions. These events provide an opportunity for all RAS assessors in the region to keep up to date with services being offered by aged care providers. During 2020/21 the PHN held 7 RAS information sessions, with a total of 148 assessors attending.

Training and communication for aged care nurses

The clinical pathway training project enhanced the clinical knowledge and skills of residential aged care facility nurses. This project aimed to improve the care of residents and build the confidence of RACF nursing staff; aiding their communication with care providers.

A nurse practitioner with expertise in local residential aged care was commissioned to deliver the project, which included training on the management of residents with unstable vital signs; recognition of early patient deterioration and end of life management.

85 nursing staff across the Brisbane North region participated in this project.


Yellow Envelope clinical handover tool

7,551 Yellow Envelopes were distributed across the region to support the transfer of clinical information for aged care residents to and from hospital.

Read more

Exercise program designed for in-home aged care

Keeping active at home

Maintaining physical strength and balance as we age is important for maintaining functional wellbeing and independence. Active at Home is an evidence-based exercise program developed for older Australians and available to organisations providing home care to older people anywhere in Australia. Support workers are upskilled through a nationally accredited unit of study, supporting their capacity to provide services based on wellness and reablement principles. Active at Home also has a unique smartphone app that supports the easy collection of evidence-based assessment data to measure client outcomes.

During 2020/21 we worked with 10 community aged care providers and trained 47 support workers to deliver the program.

Active at Home program

PHN leads sector development

Our quarterly aged care forums are well attended by a diverse range of sector representatives. The PHN’s healthy@home consortium funds these forums to support the sector in meeting the challenges of an evolving and complex aged care environment; by promoting networking, providing up-to-date sector information and showcasing quality presentations on a wide range of age care related topics.

During 2020/21 our team held 4 aged care forums, attended by over 300 representatives from across the sector.

Aged Care Forum

Aboriginal and Torres Strait Islander health and wellbeing